General Information
Fill out this form once per week
Full Legal Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Who Is Your Respiratory Therapist
*
Alex Grichuhin, RRT-RCP
Melanie Klein, RRT-RCP
Gwahm Kalindawalo, RRT-RCP
BORG Scale (How Out Of Breath Do You Feel?)
*
No Difficulty Breathing
0
1
2
3
4
5
6
7
8
9
Extremely Out Of Breath
10
0 is No Difficulty Breathing, 10 is Extremely Out Of Breath
Rate Your Pain
*
No Pain
0
1
2
3
4
5
6
7
8
9
Extreme Pain
10
0 is No Pain, 10 is Extreme Pain
How Well Do You Sleep At Night?
*
Poor Sleep
1
2
3
4
5
6
7
8
9
Sleep Very Well
10
1 is Poor Sleep, 10 is Sleep Very Well
Vitals
Typical Systolic Blood Pressure this week
*
The TOP NUMBER of your blood pressure reading (e.g. 120)
Typical Diastolic Blood Pressure this week
*
The BOTTOM NUMBER of your blood pressure reading (e.g. 70)
What Is Your Current Weight?
*
Please enter your weight in LBS
Liters Of Oxygen
*
Enter 0 (zero) if none
Typical Incentive Spirometer Volume this week
*
Best out of three (e.g. 500 mL, 1000 mL, etc.)
Typical SpO₂ This Week
*
Oxygen Reading On Your Pulse Oximeter (After 30 seconds)
Typical Pulse Rate this week
*
Found on your Pulse Oximeter
Questionnaire
How many days this week did you use your Delta-V?
*
0
1-2
3-4
5-7
Walking / Activity Level This Week
*
Minimal
Light
Moderate
High
Average Walking Distance
*
Please specify units (e.g. Feet, Steps, Miles, etc.)
Did You Ride Your Bike This Week?
*
Yes
No
Did You Experience Any Congestion This week?
*
Yes
No
Please Explain Your Congestion
*
Additional Information
Changes This Week
No Significant Changes
Breathing Worse
More Fatigue
More Cough/Congestion
Medication Changes
Illness/Infection
ER/Hospital Visit
Please Rate Your Overall Therapy Experience
*
1
2
3
4
5
Do you need an office staff member to contact you for any reason?
*
Yes
No
Do You Have Any Additional Comments Or Concerns You Would Like To Address With Your Assigned Clinician?
Would you like a one-on-one session with your respiratory therapist?
Yes, I would like a one-on-one session
Maybe — I’d like more information
No, not at this time
Acknowledgments (Required)
Accurate Information
*
I confirm that the information I entered above is accurate and current.
Terms & Conditions
*
I understand and acknowledge that Home Rehab Network LLC (HRN) is not liable for any adverse events that may occur due to the omission of any requested vital signs.
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